Consent to Telehealth Services.

I have reviewed this Consent to Telehealth Services with respect to the provision of healthcare services from Index Health’s contracted healthcare entities, including Ziemba Medical P.C. and affiliated medical providers (“Providers” or “Provider”) (Ziemba Medical P.C. and Provider/s collectively, “Index Clinic). I understand that this consent is supplemental to the Medical Terms of Service.

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By checking the box in the Index Health registration flow associated with this Consent to Telehealth, I consent to the following:

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1. I consent to receiving medical services via telehealth, and I recognize that my Provider may deem telehealth inappropriate for my specific case. I further understand that there is no guarantee that I will be prescribed any specific medication, and that any prescription or course of treatment is up to the medical and professional judgment of my Provider.
2. I understand that Index Clinic uses various security protocols, including, but not limited, to (a) maintaining network physical safeguards applicable for each system used to access, transmit, receive and store PII, PHI and sensitive company data to ensure that appropriate security is maintained and that access is restricted to authorized employees; (b) physical access rules to limit physical access to PHI, PII and sensitive company data and the physical location(s) in which such systems are housed; and (c) procedures stating how all media containing PHI, PII and sensitive company data, will be disposed of in a manner that destroys the data and does not allow unauthorized access to the data.
3. I understand that a Provider will be assigned to me. I can request a different, appropriately-licensed Provider, and that I have the right to review the credentials of my assigned Provider or a Provider of my choice.
4. If I am experiencing a medical emergency, I understand that I should contact 9-1-1 or go to the nearest emergency room. I will not use Index Health’s platform for emergency medical services. I understand that I should disclose to my Provider if I have received emergency medical services. 

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What is Telehealth?

Telehealth is the provision of medical and healthcare services in which the patient and medical provider are not in the same location. To effectuate the provision of medical services in such circumstances, healthcare providers utilize technology, such as diagnostic tools, audio communication, visual communication, and or store-and-forward technology. In some cases, telehealth services are performed synchronously (i.e., with the patient and provider interacting in real time) and in other cases telehealth services are performed asynchronously (i.e., with the patient and provider interacting at different times). Telehealth includes the creation and or transmission of an electronic patient medical record. Not all conditions are suitable for treatment via telehealth.

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Additional Notices to Patients of the Following States:

California: Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov,

email: licensecheck@mbc.ca.gov, or call (800) 633-2322. For more information visit the California Medical Board’s Notice to Consumers website.

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New Hampshire: If deemed appropriate by my Provider, I consent to having my medical records forwarded to my primary care or treating provider. (N.H. Rev. Stat. § 329:1-d).

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New Jersey: I understand that I have the right to request a copy of my medical information and, if deemed appropriate by my Provider, I affirmatively consent to having my medical information forwarded directly to my primary care provider or health care provider of record, or upon my request, to other health care providers. I understand that if I don’t have a primary care provider or other health care provider of record, my Provider may advise me to contact a primary care provider, and, upon request by me, my Provider may assist me with locating a primary care provider or other in-person medical assistance that, to the extent possible, is located within reasonable proximity to me. (N.J. Rev. Stat. Ann. § 45:1-62).

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Pennsylvania: I understand that I may be asked to confirm my consent to behavioral health or tele-psych services.

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Virginia: I have received details on security measures taken with the use of telemedicine services, such as encrypting date of service, password protected screen savers, encrypting data files, or utilizing other reliable authentication techniques, as well as potential risks to privacy notwithstanding such measures; I agree to hold harmless my Provider, the Ziemba Medical P.C., Index Clinic, and Index Health for information lost due to technical failures; and I provide my express consent to forward my patient-identifiable information to a third party. (Virginia Board of Medicine Guidance Document 85-12).

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